Afleveringen
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Over the past decade, diving fatalities have remained stubbornly consistent despite better equipment, more training, and growing participation, suggesting the problem isnât just technical or individual error. Current safety approaches focus on equipment, skills, and counting deaths, but often ignore deeper issues like communication, teamwork, decision-making, and the wider system divers operate in. Research shows that most contributing factors in incidents come from these âupstreamâ conditionsâsuch as training culture, social pressure, and organisational practicesârather than the diverâs final actions. A major gap is the lack of training and assessment in non-technical skills, which are critical for managing real-world situations under pressure. At the same time, diving lacks an effective system for learning from incidents, as divers are reluctant to report issues to organisations they believe wonât act on them. To improve safety, the industry needs a shared language around human performance, better systems for collecting and learning from data, and a culture that supports open, blame-free discussionâbecause without addressing these deeper factors, meaningful change is unlikely.
Original blog: https://www.thehumandiver.com/post/why-does-nothing-change
Links: Rebreather fatality documentation from RF4.0: https://indepthmag.com/rebreather-forum-4-proceedings-are-available-for-free-download/
DCS study from DAN: https://journals.viamedica.pl/international_maritime_health/article/view/108038
If Only⊠documentary: https://www.thehumandiver.com/ifonly
Linnea Mills case: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
Divers Alert Network reporting: https://dan.org/research-reports/research-studies/diving-incident-reporting-system/
BSAC reporting: https://www.bsac.com/home/
DOSA reporting: https://duikongevallen.nl/
LEODSI and PETTEOT: https://www.thehumandiver.com/post/what-is-leodsi-petteot
Blogs about learning from incidents: https://www.thehumandiver.com/blog/category/learning-JC-incidents
Tags: THD-English| THD-Learning, Incidents & Just Culture
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This final blog explores what the research means and how the diving community can realistically improve learning and safety. It argues that the problem is not broken individuals but a system that quietly encourages blame and silence, making it hard for divers to share honest stories about mistakes and near-misses. Fearâof legal action, criticism, or damage to reputationâplays a big role, even when that fear is not based on real outcomes. The result is weak feedback loops, where lessons from real experiences never reach the people who design training or shape the culture. The blog suggests shifting focus from the idea of a formal âjust cultureâ to a more practical âculture of justness,â where fairness, understanding, and learning are encouraged at a local level by respected leaders. It also highlights how sharing more context reduces blame and improves learning, but notes that most divers are never taught how to do this. While there is no single fix, the way forward includes clearer language, better-designed reporting systems, role modelling by instructors and experienced divers, and introducing honest discussions about incidents into training. Ultimately, meaningful change will come from gradually shifting behaviours and norms, so that sharing real experiences becomes normal, supported, and valued across the diving community.
Original blog: https://www.thehumandiver.com/post/msc-part-3-the-outcomes
Links: Part 1: https://www.thehumandiver.com/post/msc-part-1-the-problem-space
Part 2: https://www.thehumandiver.com/post/msc-part-2-the-data-and-results
The full thesis, Storytelling to Learn: What Happens Underwater, Stays Underwater, was submitted in partial fulfilment of the requirements for the MSc in Human Factors and System Safety at Lund University, 2024. Gareth Lock is the founder of The Human Diver
References:Dekker, S. (2009). Just culture: Who gets to draw the line? Cognition, Technology & Work, 11(3), 177â185. https://doi.org/10.1007/s10111-008-0110-7
EC. (2014). Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014. European Commission.
Exley, S. (1986). Basic cave diving: A blueprint for survival. National Speleological Society â Cave Diving Section. https://nsscds.org/wp-content/uploads/2018/05/Blueprint-for-Survival.pdf
Heffernan, M. (2011). Wilful blindness: Why we ignore the obvious. Simon and Schuster.
Hoffman, B. G. (2012). American icon: Alan Mulally and the fight to save Ford Motor Company. Crown.
Rasmussen, J. (1997). Risk management in a dynamic society: A modelling problem. Safety Science, 27(2â3), 183â213.
Tags: THD-English| THD-Learning, Incidents & Just Culture
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Zijn er afleveringen die ontbreken?
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This blog explains how a mixed-methods study explored why divers struggle to share honest, learning-focused stories about incidents. Using a large international survey, focus groups, and expert interviews, the research found that storytelling is strongly shaped by organisational culture, fear, and trust. Many diversâespecially instructorsâfear legal consequences, criticism, or damage to their reputation, which stops them from speaking openly, particularly in public settings. At the same time, there is confusion about key ideas like what counts as an âincident,â what âriskâ really means, and what a âjust cultureâ looks like, with very few divers linking incidents to learning. The study also showed that when stories include more context, people are less likely to judge and more likely to learn, but most divers are not taught how to do this. Overall, the findings suggest the diving community knows that sharing near-misses and building a just culture would improve safety, but lacks the trust, understanding, and organisational support needed to make that happen.
Original blog: https://www.thehumandiver.com/post/msc-part-2-the-data-and-results
Links and references: British Diving Safety Groiup: https://bdsg.org.uk/
Chan, W. T.-K., & Li, W.-C. (2023). Development of effective human factors interventions for aviation safety management. Frontiers in Public Health, 11, 1144921. https://doi.org/10.3389/fpubh.2023.1144921
EC. (2014). Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014. European Commission.
Reason, J. (2016). Managing the risks of organizational accidents. Routledge. https://doi.org/10.4324/9781315543543
Tags: THD-English| THD-Learning, Incidents & Just Culture
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This episode introduces the problem behind learning in diving safety, using the 2020 death of Linnea Mills to highlight how incidents are often caused by deeper system issues, not just individual mistakes. While near-misses and accidents happen regularly in diving, most are never shared or analysed, meaning valuable lessons are lost. Unlike industries such as aviation or healthcare, diving lacks strong reporting systems, regulation, and reliable data, so decisions are often based on uncertainty rather than evidence. Existing reports tend to focus on immediate causes like equipment failure or diver error, but miss the wider social, organisational, and environmental factors that shape outcomes. The episode argues that meaningful learning comes from âcontext-richâ stories that explain not just what happened, but why it made sense at the time. Drawing on safety research from other industries, it highlights the need for a stronger reporting culture, psychological safety, and system-level thinking to improve learning and prevent future incidents.
Original blog: https://www.thehumandiver.com/post/msc-part-1-the-problem-space
References: Dekker, S. (2017). Just culture: Restoring trust and accountability in your organization (3rd ed.). CRC Press, Taylor & Francis Group.
Drupsteen, L., & Guldenmund, F. (2014). What is learning: A review of the safety literature to define learning from incidents, accidents and disasters. Journal of Contingencies and Crisis Management, 22(2), 81â96. https://doi.org/10.1111/1468-5973.12039
EC. (2014). Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014. European Commission.
Gigerenzer, G. (2014). Risk savvy. Viking. https://www.amazon.co.uk/Risk-Savvy-Make-Good-Decisions/dp/1846144744
Lock, G. (2011). The application of the Human Factors Analysis and Classification System (HFACS) to improve diving safety. https://drive.google.com/file/d/1Iz3qRRyo2NjdiBGbPcRhj14NoCTuuM4/view?usp=share_link
Mills v Gull Dive Center PADI (2022). https://www.scribd.com/document/555406095/Mills-v-Gull-Dive-Center-PADI-2nd-Amended-Complaint
Orlady, H. W., & Orlady, L. M. (2017). Human factors in multi-crew flight operations (1st ed.). Routledge.
Reason, J. (2016). Managing the risks of organizational accidents. Routledge. https://doi.org/10.4324/9781315543543
Snowden, D. (2002). Complex acts of knowing: Paradox and descriptive self-awareness. Journal of Knowledge Management, 6(2), 100â111. https://doi.org/10.1108/13673270210424639
Waring, J. J. (2005). Beyond blame: Cultural barriers to medical incident reporting. Social Science & Medicine, 60(9), 1927â1935. https://doi.org/10.1016/j.socscimed.2004.08.055
Tags: English| Learning, Incidents & Just Culture
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This episode examines a 2012 triple fatality at Cenote Chac Mool in Mexico using a Human Factors approach, showing how accidents are rarely caused by a single mistake but by a combination of small, interacting factors. A guide took two recreational divers beyond safe limits into an overhead cave environment without a continuous guideline, and all three ran out of gas and died. Instead of simply blaming the guide, the analysis explores how things made sense at the time, including authority gradients that stopped the divers from questioning decisions, fatigue from multiple dives, pressure to show something impressive, and increasing task load in a complex environment. Using the PETTEOT framework, the case highlights how people, environment, equipment, organisational culture, and time pressures combined to reduce safety margins until there was no capacity left to recover. The key lesson is that safety depends on understanding these system interactions, building psychological safety so people can speak up, and reinforcing clear rules and preparation to prevent small, ânormalâ deviations from turning into fatal outcomes.
Original blog: https://www.thehumandiver.com/post/chac-mool-triple-diving-fatality
Links: Full CREER manual: https://creer-mx.com/wp-content/uploads/2024/03/Manual-for-Cenote-Dive-Guides-vs010324.pdf
The Thumb rule: https://www.thehumandiver.com/post/top-tips-for-diving-instructors-psychological-safety-and-the-thumb-rule
Learning from Emergent Outcomes course waiting list: https://www.thehumandiver.com/lfeo
Tags: English| Learning, Incidents & Just Culture
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This episode explores the fatal case of 18-year-old Linnea Mills to show how visible hazards can go unnoticed when an instructor lacks the mental capacity to recognise them. Linnea was overweighted, unable to inflate her drysuit, and using equipment that couldnât provide enough liftârisks that seem obvious in hindsight but were missed due to a combination of inexperience, time pressure, unfamiliar gear, and commercial expectations. Using models like ECOM and COCOM, the episode explains how an instructorâs attention can be consumed by immediate tasks, leaving no capacity to monitor the bigger picture or reassess whether a dive should proceed. This isnât about blaming an individual, but understanding how systems, workload, and limited experience can overwhelm decision-making. The key lesson is that effective instructors donât just rely on skill, but on preparationâsetting clear plans, checks, and limits before the diveâto protect their ability to recognise problems when it matters most.
Original blog: https://www.thehumandiver.com/post/the-obvious-thing-nobody-noticed
Links: Part 1: https://www.thehumandiver.com/post/the-picture-went-dark
The Linnea Mills case: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
Tags: English| Sense-making, Decision-making, & Psychology
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This episode explores why divers donât truly âloseâ situation awareness, but instead run out of the mental capacity needed to maintain it. Through the story of James on a challenging wreck dive, it shows how increasing demandsâlike current, task focus, and effortâcan quietly narrow attention until the bigger picture is lost, even when skills and training are sound. Using two human factors models, COCOM and ECOM, the discussion explains how control shifts from broad, strategic thinking to narrow, reactive behavior as workload rises, and how different layers of awarenessâfrom basic task execution to overall planningâcan break down under pressure. It highlights that mistakes are often not about poor decisions, but about limited cognitive resources in the moment. The episode also emphasizes the importance of good preparation, clear decision thresholds, teamwork, and deliberate pauses to manage workload, while showing how reflection after the dive helps improve future performance. Ultimately, it reframes the difference between novice and experienced divers as the ability to manage attention and maintain the bigger picture, not just technical skill.
Original blog: https://www.thehumandiver.com/post/the-picture-went-dark
Links: A 2026 study in Safety Science by Woltjer and colleagues: https://www.sciencedirect.com/science/article/pii/S0925753526000822
Part two: https://www.thehumandiver.com/post/the-obvious-thing-nobody-noticed
Tags: English| Sense-making, Decision-making, & Psychology
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Divers make many decisions quickly, often without realising it, by using heuristicsâmental shortcuts that help us act fast when time and information are limited. These shortcuts are essential and often effective, especially with experience, but they can also lead to predictable errors called biases when used in the wrong situation. Common examples include relying too much on recent experience, sticking to an original plan despite changing conditions, or only noticing information that supports what we already believe. In diving, where conditions vary and feedback is often limited, these biases can quietly increase risk. The key is not to avoid intuition, but to understand when it might be misleading and to slow down when needed. Tools like checklists, realistic training, and open team communication help balance fast thinking with more careful decision-making, improving safety and helping divers make better choices underwater.
Original blog: https://www.thehumandiver.com/post/shortcuts-errors-and-the-gap
Links: Gigerenzerâs push for people to be ârisk savvyâ: https://www.jasoncollins.blog/posts/nudging-citizens-to-be-risk-savvy
Blog about the Scylla wreck tragedy: https://www.thehumandiver.com/post/scylla-wreck-penetration-leodsi
Blog about the IJN Sata incident: https://wreckedinmyrevo.com/2023/11/16/close-call-on-the-ijn-sata-palau-120-fsw/
Tags: English| Sense-making, Decision-making, & Psychology
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Diving operations rarely fail because people lack skill; they fail when skilled individuals are not supported by the systems around them. The Resilient Performance Model from The Human Diver explains that performance comes from the interaction of three areas: technical skills, non-technical skills like communication and decision-making, and the wider context such as culture, workload, and resources. When one of these areas is weak or missing, problems appearâsuch as highly skilled divers working in silence, well-coordinated teams lacking critical skills, or strong systems where people feel unable to challenge decisions. True resilience happens when all three are aligned, allowing teams to adapt when things go wrong and still achieve safe outcomes. The key lesson is that improving safety isnât just about better training or stricter procedures, but about creating an environment where people can speak up, make good decisions under pressure, and learn from both successes and failures to improve over time.
Original blog: https://www.thehumandiver.com/post/resilient-performance-model
Tags: Commercial Diving
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When something goes wrong in diving, people often ask âwho made the mistake?â, but that question usually oversimplifies what really happened and stops us from learning. The Learning from Emergent Outcomes framework (LEODSI) takes a different approach by looking at diving as a system, where outcomes are shaped by many interacting factors rather than one personâs actions. It examines seven key elementsâpeople, environment, tasks, equipment, external pressures, organisation, and timeâto understand how decisions made sense in the moment and how conditions combined to produce the result. Instead of blaming individuals, LEODSI focuses on why events unfolded the way they did, recognising that both successes and failures come from the same system. By using this approach in everyday debriefs, not just after incidents, divers and teams can learn more effectively, improve safety, and make meaningful changes that reduce risk in the future.
https://www.thehumandiver.com/post/what-is-leodsi-petteot
Links: Learning from Emergent Outcomes course: https://www.thehumandiver.com/lfeo
Tags: Learning, Incidents & Just Culture
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This piece explores how diving incidents are often misunderstood by focusing too quickly on blame rather than learning. It explains the important difference between responsibility (who was involved) and accountability (who answers for the outcome), showing that incidents are usually caused by a chain of decisions, pressures, and system factorsânot just one personâs mistake. By comparing âblame questionsâ (who is at fault?) with âlearning questionsâ (why did it make sense at the time?), it highlights how real improvement comes from understanding the conditions that led to an error. Through examples like missed safety checks, risky habits becoming normal, ignored concerns, and unreported near-misses, the text shows how blame cultures stop people speaking up and allow problems to grow. Instead, it argues for a learning-focused approach where divers, instructors, and organisations reflect on decision-making, encourage honest reporting, and examine the wider system. The key message is that accountability should not be about punishment, but about creating an environment where people can speak openly, learn from mistakes, and prevent future incidents.
Original blog: https://www.thehumandiver.com/post/youre-accountable-youre-responsible-youre-it
Links: Blog about the Scylla wreck incident: https://www.thehumandiver.com/post/scylla-wreck-penetration-leodsi
IJN SATA case study: https://wreckedinmyrevo.com/2023/11/16/close-call-on-the-ijn-sata-palau-120-fsw/
Blog about Linnea Mills: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
PDF guide: https://drive.google.com/file/d/1Ugx0lQM5am2gQ9rJa4aCq39JBukGZyLK/view?usp=sharing
Ruth Parris: https://www.linkedin.com/in/ruth-parris-76a53635/
Ruthâs thesis: https://lup.lub.lu.se/student-papers/search/publication/9186204
Tags: English| Learning, Incidents & Just Culture
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This blog by Michael John Snow explores how small equipment issues on a remote expedition vessel can gradually become accepted as ânormal,â not because of poor decisions, but because of how isolated systems work. In these environments, teams are skilled and focused on keeping operations running, especially when guests, tight schedules, and limited support make stopping costly. With fewer external checks and less immediate feedback, minor irregularities are often monitored rather than acted on, and over time they fade into the background. This process, known as normalization of deviation, slowly shifts what is seen as acceptable without anyone clearly deciding to take a risk. When a problem finally forces action, it can look sudden, but it is usually the result of many reasonable choices made over time. The key message is that this isnât about individual failure, but about system design: isolation reduces challenge, delays response, and makes it easier for risk to build unnoticed. To manage this, the blog argues that remote operations need stronger structuresâlike clear governance, tracking, and shared visibility of equipment performanceâso that small issues stay visible and are addressed before they become bigger problems.
Original blog: https://www.thehumandiver.com/post/isolation-amplifies-drift
Links: Governance mechanisms: https://remoteassetgovernance.com/framework
Tags: English| Operations & Procedures
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This episode looks at the 2021 wreck diving tragedy on HMS Scylla, where three experienced divers entered the wreck and only one survived. It first examines the kind of reaction often seen on social media, where the incident is explained as a series of obvious mistakes made by individuals. It then explores the same event using a human factors and systems approach called LEODSI, which looks at how people, environment, equipment, tasks, organisational culture, and time interact to shape decisions and outcomes. Instead of asking âwho failed?â, this perspective asks how normal behaviour, built on experience, trust, and familiar conditions, can combine with changing environments, increasing stress, and limited time to slowly reduce safety margins. By understanding how these factors interacted to produce the outcome, the aim is to help the diving community learn in a deeper way and improve the overall system so that safer decisions become easier and tragedies like this are less likely to happen.
Original blog: https://www.thehumandiver.com/post/scylla-wreck-penetration-leodsi
Links: Interview with Adam on the Deep Wreck Diver Youtube channel: https://www.youtube.com/watch?v=OMYKjZocins
Linnea Mills Case: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
Death of a 12 year old in Texas during Open Water training: https://www.thehumandiver.com/post/learning-from-tragedy-dh
Learning from Emergent Outcomes: https://www.thehumandiver.com/lfeo
Dive Talk review of the interview: https://www.youtube.com/watch?v=WvCr3_pX4a4
Tags: English| Learning, Incidents & Just Culture
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This episode explores the serious incident in which two divers were accidentally left behind by a dive boat near Rottnest Island while diving with Perth Diving Academy. Rather than treating it as the failure of one operator, the discussion looks at how a simple errorâsuch as a headcount mistakeâcan reveal deeper weaknesses in safety systems that may exist across the dive charter industry. It explains how many operations rely on habits, assumptions, and informal checks that usually work, but can fail when conditions change. The episode also looks at the limits of fines and punishment, which rarely help the wider industry learn unless there is transparency about what actually went wrong. Instead of blaming a âbad operator,â the focus is on understanding how safety systems drift over time, why single points of failure are dangerous, and how stronger safety comes from multiple checks, open feedback from staff and customers, and a culture of continuous improvement that looks for problems before they turn into accidents.
Original blog: https://www.thehumandiver.com/post/this-could-happen-to-any-dive-operator
Links: Australian Maritime Safety Authority: https://www.amsa.gov.au/
How we measure safety in diving: https://www.thehumandiver.com/post/what-does-safe-mean
Systems in diving: https://www.thehumandiver.com/post/the-road-to-excellence-systems-and-structure-form-the-foundation-of-a-culture-of-improvement
Tags: English| Learning, Incidents & Just Culture
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This episode looks at how diving incidents are often explained by blaming the last person involved, much like blaming the person who pulls the final brick from an already unstable Jenga tower. While that person may be the last to act, many other factorsâsuch as environment, equipment, training, social pressure, and organisational practicesâmay already have weakened the system. Through several real diving examples, the episode shows how accidents usually develop from a combination of conditions rather than a single mistake. It also explains why people are quick to blame individuals: it is easier, it protects our sense of safety, and it is what we are used to seeing in the media and official reports. Instead of asking what someone âshould have done,â the more useful question is how their actions made sense at the time with the information and resources they had. By shifting from judgement to curiosity and looking at the wider system, divers and instructors can learn more from incidents and improve both their technical and non-technical skills to make future dives safer.
Original blog: https://www.thehumandiver.com/post/and-still-the-tower-is-standing
Links: âBlaming a bad apple is like wetting your pantsâ:https://indepthmag.com/do-bad-apples-actually-exist/
Blog about the death of Linnea Mills: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
Blog about the death of a 12 year old child in Texas: https://www.thehumandiver.com/post/learning-from-tragedy-dh
Wait list for Learning from Emergent Outcomes course: https://www.thehumandiver.com/lfeo
Facebook group: https://www.facebook.com/groups/184882365201810/permalink/2729409417415746/
Tags: English| Safety & Risk Management
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This episode looks at how quick judgement, especially online, can block learning and make diving less safe. Using a real example of an adaptive scuba training video that received harsh criticism, it explains how people often react without understanding the full context. The episode introduces two key ideas from Human Factors: psychological safety, where people feel safe to ask questions and speak up, and just culture, where the focus is on learning instead of blame. The main message is simple: when people judge, learning stops, but when people stay curious, learning begins. By slowing down, asking questions, and trying to understand why decisions made sense at the time, dive teams and the wider community can make better choices, create safer environments, and build a healthier culture for everyone.
Original blog: https://www.thehumandiver.com/post/be-curious-not-judgemental
Links: Original Facebook post and video: https://www.facebook.com/share/r/1DnwV8qM1r/
Tags: English| Learning, Incidents & Just Culture
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This episode explores why people often go diving even when something feels âoff,â and how risk usually starts before anyone gets in the water. It explains that danger doesnât come from one big mistake, but from small pressures like stress, tiredness, rushing, poor communication, and cutting corners that slowly build up and start to feel normal. Over time, these small compromises become habits, and people stop seeing them as problems at all. The key message is that safety isnât just about following procedures underwater â itâs about noticing when your safety margin is already shrinking on the surface. Real safety comes from having the courage to stop, slow down, and ask not âCan we do this dive?â but âDo we still have enough room for things to go wrong?â
Original blog: https://www.thehumandiver.com/post/you-are-entering-water-with-known-problems
Links: Work as Imagined vs Work as Done blog: https://www.thehumandiver.com/blog/Work-as-Imagined-vs-Work-as-Done
Tags: English| Safety & Risk Management
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This episode explores what real safety improvement in diving could look like if we stop copying other industries and start designing for the reality of diving itself. It explains that diving is commercial, lightly regulated, and full of everyday trade-offs between safety, money, time, and training, which means risk canât be removed â only managed. Instead of relying only on rules and checklists, the focus should be on building âmarginâ into the system: better training time, safer conditions, lower ratios, rested instructors, better decision-making, and a culture where stopping a dive is normal, not failure. The key message is that safety doesnât come from paperwork alone, but from building real capacity â skills, time, support, learning systems, and honest culture â so people can make good decisions under pressure and prevent small compromises from slowly turning into serious danger.
Original blog: https://www.thehumandiver.com/post/no-silver-bullets-build-capacity
Tags: English| Learning, Incidents & Just Culture
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This episode looks at the tragic death of 12-year-old D.H. during a scuba training dive and explains it not as one personâs mistake, but as a failure of the whole system around her. Using court documents and a safety science approach, the analysis shows how many ânormalâ things came together â rushed training, poor visibility, tired staff, missing safety equipment, weak rules, money pressure, and lack of oversight â to create a situation where there was no real safety margin left. The key message is that this was not a random accident or a single bad decision, but the result of a system that allowed risky practices to become normal. The goal is not blame, but learning: understanding how everyday routines, shortcuts, and pressures can slowly increase danger, and how changing the system â not just individuals â is the only real way to prevent this from happening again.
Original blog: https://www.thehumandiver.com/post/learning-from-tragedy-dh
Links: Court filings: https://www.documentcloud.org/documents/26789283-dylanharrisonlawsuit/
Purpose of investigation blog: https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigation
Learning from Emergent Outcomes and LEODSI: https://www.thehumandiver.com/lfeo
Psychological safety: https://lup.lub.lu.se/student-papers/search/publication/9151225
Research around âstop workâ orders: https://www.researchgate.net/publication/352017590_Deciding_to_stop_work_or_deciding_how_work_is_done
https://www.sciencedirect.com/science/article/abs/pii/S0925753517308871
RSTC guidance and Standards: https://www.youtube.com/watch?v=kNRrrosDJYs
Trade off between performance, cost and resources: https://youtu.be/vtgIwHrUWVQ?list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&t=555
Regulated environments such as military aviation: https://www.mdpi.com/2313-576X/8/2/37
Barriers to learning from adverse events: https://lup.lub.lu.se/student-papers/search/publication/9151225
Social acceptance of drift: https://www.thehumandiver.com/post/normalisation-of-deviance-not-about-rule-breaking
Work as Imagined vs Work as Done: https://youtu.be/vtgIwHrUWVQ?list=PLNXuyLsCTX6hHS3newpcROfJ_JiI27q3C&t=962
Performance Influencing Factors: https://www.thehumandiver.com/post/top-tips-for-diving-instructors-performance-influencing-factors
The shoot down of two Black Hawks: https://www.mindtherisk.com/literature/150-friendly-fire-the-accidental-shootdown-of-u-s-black-hawks-over-northern-iraq-by-scott-a-snook
Rebreather Forum 4.0 talk: https://www.youtube.com/watch?v=nkdVHBDnCjc
Challenger and Columbia disasters: https://www.montana.edu/rmaher/engr125/CAIB-History%20as%20a%20cause.pdf
Loss of HMNZ Manawanui: https://nzdf.mil.nz/court-of-inquiry-hmnzs-manawanui
The death of LCpl Partridge: https://assets.publishing.service.gov.uk/media/5d305623ed915d2feeac4a0f/LCpl_Partridge_Service_Inquiry_Parts_1.1._to_1.6_REDACTED_ONLINE_VERSION.pdf
The death of ADR Yarwood: https://www.nzdf.mil.nz/assets/Uploads/DocumentLibrary/Redacted-Death-Able-Diver-COI-Rpt-for-publication.pdf
Safety Science for Outdoor and Experiential Learning book: https://www.amazon.com/Safety-Science-Outdoor-Experiential-Education-ebook/dp/B0G99BD12G/ref=sr_1_1
The death of Linnea Mills: https://www.thehumandiver.com/post/linnea-mills-death-hf-systems-lens
Tags: English| Learning, Incidents & Just Culture
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This episode explores why asking âwhy did this happen?â after a diving accident is important â but not enough on its own. It explains that investigations often stop too early, not because everything is understood, but because people reach a point that feels comfortable, simple, or easy to fix. Many reports focus on equipment failures or individual mistakes, while deeper causes like pressure, workload, training culture, time limits, and business realities are left out. The episode shows that real learning comes from looking at how normal routines, shortcuts, and everyday decisions shape what people do, not just what went wrong at the end. The main message is clear: the goal of asking âwhyâ isnât to find someone to blame, but to understand the system well enough to change future behaviour â so the next dive is safer, even under pressure and imperfect conditions.
Original blog: https://www.thehumandiver.com/post/when-do-we-stop-asking-why
Links: Learning from Emergent Outcomes and LEODSI: https://www.thehumandiver.com/lfeo
Some relevant blogs: https://www.thehumandiver.com/post/what-story-gets-told-what-words-are-used
https://www.thehumandiver.com/post/when-the-story-hurts-too-much
https://www.thehumandiver.com/post/what-is-the-purpose-of-an-investigation
References:
Kletz, T. A. (2006). Accident investigation: Keep asking âwhy?â. Journal of hazardous materials, 130(1-2), 69-75.
Reason, J. (2016). Managing the risks of organizational accidents. Routledge.
Reason, J. (1991). Too little and too late: A commentary on accident and incident reporting systems. In Near miss reporting as a safety tool (pp. 9-26). Butterworth-Heinemann.
Rasmussen, J. (1990). Human error and the problem of causality in analysis of accidents. Philosophical Transactions of the Royal Society of London. B, Biological Sciences, 327(1241), 449-462.
Rasmussen, J. (1988). Coping safely with complex systems. In AAAS Annual Meeting 1988.
Cedergren, A., & Petersen, K. (2011). Prerequisites for learning from accident investigationsâa cross-country comparison of national accident investigation boards. Safety Science, 49(8-9), 1238-1245.
Lessons from Longford: the Esso Gas Plant Explosion. Andrew Hopkins. CCH Australia, Sydney. 2000
Lundberg, J., Rollenhagen, C., & Hollnagel, E. (2010). What you find is not always what you fixâHow other aspects than causes of accidents decide recommendations for remedial actions. Accident Analysis & Prevention, 42(6), 2132-2139.
Manuele, F. A. (2016). Root-Causal Factors: Uncovering the Hows & Whys of Incidents. Professional Safety, 61(05), 48-55.
Tags: English| Learning, Incidents & Just Culture
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